Amplitudes of Accommodation & Accommodative Facility o Accommodation: the change in dioptric power of the crystalline lens allowing focal

point change o Amplitude of accommodation: amount of accommodation as measured from the far point to the near point with max exertion Accommodative response is generally equal in both eyes Accommodative response does not always equal to the stimulus Clinician may not be controlling test properly Amplitude decreases with age at the rate of 0.30 D/year from ages 5 to 52 Myopes have an advantage over hyperopes Decreased amplitudes= accommodative insufficiency Prediction of amplitude based on age o Minimum amplitude = 15 0.25 x age o Can use Donders or Duanes Tables Reduced amplitude of accommodation usually produces symptoms such as blurring, eye fatigue, headaches, diplopia, wearing, etc Onset of symptoms depends on near point demands Donders Push-Up Method Test with habitual Rx or manifest refraction Direct stand lamp toward near target o Target: a near threshold size letter or row (20/20, 20/25) Test monocularly first and then binocularly o Note: binocular is not a true measure because of the vergence system Start at ~50cm and push-up at 5cm/sec and repeat for a total of 3 Measure the distance in cm and convert to diopters; record all 3 measurements Minus Lens Method Test with manifest distance correction in the phoropter Test monocular and at 40 cm with 20/20 LOL Add minus lenses in 0.25D steps Maximum amplitude = lenses added + 2.50D Note: the minus lens method is usually less than the pushup method o As you move the target closer with the push-up method, there is a larger angle subtended on the retina o Also, minus lenses minify the letters

o Accommodative facility: ability to change accommodative status rapidly and accurately Measures accommodative flexibility Depends on patients ability to observe the blur and be attentive enough to report in a timely way (very subjective) Near-far alternative fixation test Manifest distance correction and test monocularly Use a BVA target at 6m and at 40cm Record the number of cpm (cycles per minute) for OD, OS Flipper Bar Method Manifest distance correction with high illumination Use a target close to threshold VA on near point card at 40 cm Flip the +/- 2.00 D for 1 min for OD, OS, OU (3 min total) Record cpm Norms o Monocular: age 13-30 using the +/- 2.00 >/= 11 cpm (+5) o Binocular: age 13-30 using the +/- 2.00 >/= 8 cpm o Other accommodative tests NRA: negative relative accommodation Add plus lenses until patient reports first sustained blur (how much you can relax) PRA: positive relative accommodation Add minus lenses until patient reports first sustained blur (how much you can stimulate) Range: 1/3 In and 2/3 Out; good for prescribing o Conditions Spasms of accommodation Accommodative fatigue Near Point of Convergence o Near point of convergence: maximum amount of convergence a patient can sustain while maintaining single vision on a target Tests the strength of binocular fusion: positive fusional vergence Should not change with age Patients with reduced NPC may report diplopia, fatigue with near tasks, and decreased reading comprehension o Procedure Use a tip of a pen or penlight or an accommodative target and habitual Rx Have patient hold tape measure at outer canthus Start at ~50 cm and EYE LEVEL and move target toward patients nose

Instruct patient to tell me when the target breaks into two It is okay if the target is blurry After diplopia, instruct patient to tell me when it comes back to one Endpoint is either subjective or objective Measure NPC from the outer canthus to the break point Outer canthus is the closest point to center of rotation of the eye If you measured from the bridge, would have to add 2.7 cm to get the center of rotation Record break/recovery, suppression or diplopia If suppression, note the deviating eye and direction of deviation Can use TB (to bridge) or TTN (to the nose) Norms Children: 6 cm Adults: 5cm/7cm